The Sydney Modified Alberta Reconstruction Technique for dental rehabilitation following mandibulectomy or maxillectomy

Executive summary

The Sydney Modified Alberta Reconstruction Technique (SM-ART) is a two-stage, occlusion-driven method for immediate vascularized jaw reconstruction with primary dental implants and deliberate creation of stable peri-implant soft tissue.

Its planning sequence is:

Planned dentition and occlusion -> prosthetic envelope -> implant positions -> vascularized bone position -> osteotomies and fixation

The distinctive step is a buried split-thickness skin graft around the implants beneath the flap skin paddle. At a second operation, that graft becomes fixed peri-implant "neogingiva," while the mobile skin paddle is displaced buccally and lingually. This is intended to improve implant emergence, vestibular anatomy, hygiene access, and long-term peri-implant stability.

SM-ART is not synonymous with "jaw-in-a-day." The implants are placed during the primary reconstruction, but exposure and definitive prosthetic rehabilitation are delayed.

Evidence warning: The original SM-ART report is a nine-patient technical note, not a controlled trial. This guide distinguishes the published technique from practical implementation recommendations. Case selection and operative decisions must remain patient-specific and subject to local multidisciplinary governance.

Relationship to other reconstructive protocols

Protocol	Implant and bone workflow	Soft tissue and prosthetic timing
Conventional reconstruction	Bone contour is prioritized; implants are often delayed	Dental rehabilitation may be protracted or never completed
Rohner prefabrication	Implants, grafting, and prefabrication occur in the leg before flap transfer	Excellent planned tissue interface, but the delay makes it difficult to use for urgent malignancy
Alberta Reconstruction Technique (ART)	Implants are guided into the vascularized fibula in the leg; an implant-supported transfer template controls the fibular segments and relates them to the dentition	Implants are exposed after oncologic treatment and healing; a soft-tissue stent precedes the prosthesis
SM-ART	The custom-plated flap is inset and revascularized first; implants are then guided intraorally in their definitive bone position	A buried skin graft matures beneath the skin paddle; implants and graft are exposed at stage II
Jaw-in-a-day	Implants and a provisional prosthesis are delivered at the primary reconstruction	Immediate dental restoration, with a different risk and soft-tissue pathway

The original ART is a two-stage, fully guided workflow. Its transfer template compensates for rotational freedom in the fibular construct by indexing the implants and remaining dentition. Contemporary descriptions remain explicitly occlusion-first and prosthetically driven.

The workspace file named Alberta Reconstruction Technique.pdf is actually a 2011 prospective simulation study of three-dimensional biomodel-assisted plate bending, not the 2019 ART clinical study. It supports the accuracy of planned geometry but does not evaluate implant placement or dental rehabilitation.

Appropriate case selection

A favorable candidate generally has

A segmental mandibular or osseous maxillary defect requiring vascularized bone.
A realistic objective of fixed implant-supported dental rehabilitation.
Sufficient time and anatomical predictability for reliable virtual surgical planning.
A defect in which a conventional skin paddle around the implants would likely be bulky, mobile, poorly cleansable, or vestibularly deficient.
Adequate donor bone and soft tissue, acceptable implant corridors, and suitable recipient vessels.
The motivation and dexterity, or caregiver support, required for lifelong peri-implant maintenance.
Access to a multidisciplinary team capable of completing stage II and prosthetic delivery.

Primary implants without a funded and scheduled rehabilitation pathway are not SM-ART in any meaningful functional sense.

Use caution or consider another pathway when

Resection margins are highly uncertain or likely to expand beyond the virtual plan.
The patient is medically unlikely to tolerate a planned second procedure.
Surveillance, hygiene, or prosthetic attendance will be unreliable.
There is severe active infection, poor recipient tissue, uncontrolled disease, or inadequate donor geometry.
A maxillary obturator is the intended definitive rehabilitation.
The implant guide cannot achieve rigid, unambiguous seating on the final flap configuration.
Plate, osteotomy, pedicle, and implant corridors cannot be separated safely.

Edentulism is not necessarily an absolute contraindication: contemporary ART planning can create a virtual dentition. However, loss of tooth-supported intraoperative indexing makes transfer and rotational control more demanding.

Radiotherapy considerations

The original SM-ART authors favored:

Prefabrication or prelamination for benign disease.
SM-ART for malignancies requiring immediate osseous reconstruction.
Secondary reconstruction when postoperative radiotherapy was expected, especially where delayed maxillary reconstruction would not disrupt the interim occlusal relationship.

This is not a universal rule. More recent observational cohorts support primary implant placement in selected oncologic patients, including patients receiving postoperative radiotherapy. A 148-patient cohort found that dental rehabilitation was completed more often and earlier after immediate implant placement: 69.8% versus 25.8%, with median rehabilitation at 120 versus 355 days. This was not a randomized SM-ART study.

Radiotherapy nevertheless remains a major risk modifier. A recent 53-patient, 257-implant reconstructed-jaw cohort reported 91.8% overall five-year implant survival but 73.8% after adjuvant radiotherapy. Primary implantation may avoid later drilling into irradiated bone, but it does not protect the flap, plate, soft tissue, or implants from subsequent radiation injury.

Preoperative planning

1. Build the team before building the model

The core team should include:

Ablative surgeon.
Reconstructive or microvascular surgeon.
Implant surgeon.
Maxillofacial prosthodontist and dental technician.
Virtual surgical planning engineer.
Restorative hygienist or periodontist.
Radiation oncologist when postoperative radiotherapy is plausible.

The prosthodontist must participate before bone positioning is finalized.

2. Define the dental endpoint

Start with:

Preserved and planned dentition.
Occlusal plane and interarch relationship.
Desired dental arch and tooth position.
Prosthetic vertical space.
Implant emergence and screw-access directions.
Lip, tongue, and cheek clearance.
A cleansable prosthetic underside and realistic access for brushes or irrigators.

The objective is not merely to insert implants. It is to place usable implants that support a hygienic prosthesis.

3. Reverse-plan the reconstruction

The virtual sequence should be:

Establish the oncologically appropriate resection.
Construct the desired dental arch and occlusion.
Position implants prosthetically.
Move and segment the fibula or other vascularized bone to support those implants.
Design fixation around the bone and implant plan.
Recheck facial contour, condylar relationships, buttresses, pedicle orientation, and soft-tissue requirements.

For mandibular reconstruction, deliberately resolve the tension between reproducing the inferior border and placing bone sufficiently close to the occlusal plane. A cosmetically accurate lower border with a very low fibula can produce excessive crown height, unfavorable biomechanics, and poor hygiene. Double-barrel reconstruction is one possible solution but is not automatically necessary.

4. Design the hardware and guides

The SM-ART package normally requires:

Native-jaw resection guides.
Donor-bone osteotomy guides.
Patient-specific fixation plate or plates.
An implant guide customized to the final contoured flap and, when available, residual dentition.
A provisional or healing-stent plan.
A conventional rescue plan if margins or anatomy invalidate the digital reconstruction.

Perform digital collision checks among implants, plate screws, osteotomy lines, pedicle or perforator territory, and segment junctions.

The plate should be positioned as far from the future occlusal surface as the reconstruction permits and covered generously with vascularized tissue. This was specifically emphasized after hardware problems in irradiated SM-ART patients.

5. Establish a margin-change rule

Oncologic clearance must overrule the virtual surgical plan. Before surgery, decide what degree of resection change can be accommodated by alternate guides or plate holes and what change requires abandoning the implant portion of the plan. A technically perfect dental reconstruction must never constrain tumor clearance.

Stage I: Primary reconstruction

The published fibula workflow is approximately as follows.

Perform the oncologic resection using the planned guides, provided the actual margins remain compatible with the plan.
Harvest the osteocutaneous fibula. The paper used ipsilateral fibula for mandibular and contralateral fibula for maxillary reconstruction, but this is the authors’ convention rather than an anatomical rule. Pedicle geometry, recipient vessels, skin-paddle orientation, and perforators take priority.
Apply the donor cutting guide, perform the fibular osteotomies, and secure the segments to the patient-specific plate or miniplates.
Divide the pedicle, transfer the construct, and fix it into the mandibular or maxillary defect.
Perform the microvascular anastomoses.
After revascularization, seat the implant guide intraorally on the definitive fibular configuration and remaining dentition where possible. This is a central SM-ART modification: implant drilling occurs after the bone has assumed its final position.
Place the implants. The paper typically used 3.75-mm bicortical implants. This is a reported technique, not a universally required diameter. Implant dimensions should follow actual fibular width, restorative requirements, system validation, and primary stability.
Attach universal abutments and impression copings. Take an intraoperative abutment-level impression, remove the copings, and replace them with healing abutments.
Harvest a split-thickness skin graft from the inner donor leg. The reported graft was 14/1000 inch thick, approximately 0.36 mm, and about 1 inch or 25 mm wide.
Place the graft over the fibular periosteum with attached peroneal muscle fibers and around the healing abutments. Secure it with 4-0 rapidly absorbing polyglactin.
Apply a silicone sheet loosely over the graft. Its purpose is to prevent areas of incomplete graft take from adhering to the overlying skin paddle.
Lay the fibula skin paddle over the implant-graft-silicone construct and inset it conventionally.

Intraoperative stop points

Before closure, explicitly verify:

Passive and unique seating of every guide.
Planned occlusion and arch relationship.
Absence of unintended flap-segment rotation.
Implant trajectories and restorative screw access.
Primary implant stability and absence of cortical fracture.
No collision between implants and fixation screws.
Pedicle and skin-paddle perfusion after implant drilling.
Broad, immobile graft contact without hematoma.
A loosely placed, documented silicone separator that can be found at stage II.
Adequate hardware coverage.

The authors’ reason for intraoral implantation is important: a custom plate controls much of the translational geometry but may not completely control bone rotation. Implanting the fibula in the leg can therefore convert a small rotational transfer error into a major prosthetic error.

The buried interval

The published minimum was:

Six weeks without radiotherapy.
Three months when radiotherapy was given.

In the nine reported cases, the median interval from resection to implant exposure was 132 days, with a range of 77 to 661 days.

These are descriptive values, not a universal loading guideline. Stage II should also depend on:

Flap and wound healing.
Implant stability and expected osseointegration.
Bone union and plate condition.
Completion and acute effects of oncologic treatment.
Surveillance findings.
Whether a second operation remains medically appropriate.

Stage II: Creation of the peri-implant zone

Incise the skin paddle longitudinally along the axis of the fibular bone.
Move one half lingually or palatally and the other buccally.
Remove the silicone sheet, exposing the mature skin graft and healing abutments.
Assess graft take, implant stability, tissue thickness, granulation, and infection.
Debulk the skin paddle when necessary.
Suture the free margins of the skin paddle to the skin graft. The graft becomes the fixed peri-implant surface; the more mobile paddle provides adjacent lining without attaching directly around the implants.
Remove the healing abutments and connect the prosthetic components.
Secure an acrylic healing stent, or in selected cases a fixed bridge, based on the stage-I impression.
Maintain the stent until granulation has resolved and the graft-paddle junction is fully epithelialized.
Proceed to the fixed definitive prosthesis only when the tissues are stable and the design is demonstrably cleansable.

The biological precursor for this component was a five-patient submerged split-thickness skin-graft series: 18 implants, later vestibuloplasty, and healthy grafted peri-implant tissue at a mean 18 months. This is encouraging but preliminary evidence.

Main failure modes

Failure mode	Prevention or response
Oncologic resection exceeds the plan	Prioritize margins; use the backup reconstruction and abandon guided implantation if necessary
Implant guide rocks or seats falsely	Require rigid, inspectable, unique indexing; add stable bone or dental stops
Fibula rotates within the custom plate	Confirm occlusion and guide seating after definitive fixation; do not assume the plate fully controls rotation
Implants collide with screws or osteotomies	Perform digital collision checks and preserve safety corridors
Plate lies close to the occlusal surface	Lower it where feasible and maximize vascularized tissue coverage
Partial graft loss	Preserve viable graft, prevent paddle adhesion with the separator, and consider later grafting or vestibuloplasty
Bulky or mobile tissue around implants	Debulk at stage II and establish a fixed grafted peri-implant zone
Early peri-implant inflammation	Delay the definitive prosthesis until epithelialization; improve emergence and hygiene access
Radiation-associated exposure or loss	Coordinate radiation planning, minimize hardware prominence, intensify surveillance, and counsel realistically
Successful implants but no functional rehabilitation	Preauthorize and schedule stage II, prosthodontics, and maintenance before undertaking stage I

What the evidence shows

Original SM-ART report

The original publication is a technical note, not a comparative trial:

9 patients: 6 mandibular and 3 maxillary reconstructions.
7 fibula and 2 deep circumflex iliac artery flaps.
34 implants.
2 implant failures.
1 partial skin-graft loss.
1 post-radiotherapy plate exposure.
Median 132 days to implant exposure.
No complete skin-graft failures reported.

The sample is too small and heterogeneous to estimate true implant, graft, or hardware survival.

ART comparative evidence

The ART comparison involved 15 ART and 15 matched conventional reconstructions. Both groups had zero flap loss and approximately 4% implant loss, but ART used more of the implants placed, 96% versus 83%, and reduced mean time to dental rehabilitation from 73.1 to 21.4 months. These findings support occlusion-driven primary implantation but do not prove that SM-ART’s soft-tissue modification is superior.

Long-term maintenance

Long-term maintenance remains decisive. In one six-year fibula-free-flap implant cohort, implant survival was 93.6%, but peri-implantitis affected 29% of implants and 96% of patients; 52% of prostheses did not permit adequate hygiene access. A surviving implant beneath an uncleanable prosthesis is not a satisfactory endpoint.

Practical service-adoption checklist

Before offering the first cases, establish:

A written selection and radiotherapy policy.
A reproducible CT, dental-scan, and virtual-planning protocol.
Joint surgeon-prosthodontist plan approval.
Validated guide tolerances and a documented seating test.
Digital collision assessment for every implant and screw.
A margin-expansion rescue pathway.
Physical confirmation of all implant, abutment, impression, graft, separator, and stent components before anesthesia.
A planned date or window for stage II.
A prosthesis designed around hygiene access rather than tooth appearance alone.
Baseline clinical photographs and radiographs after loading.
A peri-implant maintenance pathway with closer follow-up for irradiated patients, smokers, poor hygiene, or bulky soft tissue.
Prospective audit of flap survival, graft take, plate exposure, implant utilization, time to prosthesis, diet, speech, and patient-reported function.

Take-home algorithm

Occlusion first -> place the bone for the implants -> implant only after definitive flap positioning -> bury the implants in a fixed grafted tissue bed -> expose and create the vestibule at stage II -> deliver a cleansable fixed prosthesis -> maintain indefinitely.

That sequence is the essence of SM-ART.

References

Johal M, Leinkram D, Wallace C, Clark JR. The Sydney Modified Alberta Reconstruction Technique (SM-ART) for dental rehabilitation following mandibulectomy or maxillectomy. International Journal of Oral and Maxillofacial Surgery. 2021;50:615-618. doi: 10.1016/j.ijom.2020.09.013. Local source: The Sydney Modified Alberta Reconstruction Technique (SM- ART) for dental rehabilitation following mandibulectomy or maxillectomy.pdf.
Seikaly H, Idris S, Chuka R, et al. The Alberta Reconstructive Technique: An Occlusion-Driven and Digitally Based Jaw Reconstruction. Laryngoscope. 2019;129(Suppl 4):S1-S14. doi: 10.1002/lary.28064.
Nayar S, et al. Alberta reconstructive technique: an innovative approach using digital surgical design and simulation in advanced jaw reconstruction with occlusion-based prefabricated vascularized fibular flaps and primary osseointegrated implant installation. Head & Neck. 2024. doi: 10.1002/hed.27792.
Dziegielewski PT, Zhu J, King B, et al. Three-dimensional biomodeling in complex mandibular reconstruction and surgical simulation: prospective trial. Journal of Otolaryngology-Head & Neck Surgery. 2011;40(Suppl 1):S70-S81. doi: 10.2310/7070.2010.100094. Local source: Alberta Reconstruction Technique.pdf.
Fang W, Ma W, Ma WG, Li DH, Liu BL. A new submerged split-thickness skin graft technique to rebuild peri-implant keratinized soft tissue in composite flap reconstructed mandible or maxilla. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2012;113:e4-e9. PMID: 22676834.
Allen RJ Jr, Zhang KK, Cohen Z, et al. Long-Term Outcomes Following Immediate Dental Implant Placement in Free Fibula Flaps for Oncologic Mandibular Reconstruction. Journal of Reconstructive Microsurgery. Epub 2025. PMID: 40681154.
Kim H, Roh T, Banegas DW, et al. Is immediate dental implant in fibula free flap beneficial for implant survival and osteoradionecrosis in jaw reconstruction? Oral Oncology. 2024;156:106945. PMID: 39002300.
Pieralli S, et al. Clinical outcomes and periodontal conditions of dental implants placed in free fibula flaps: a retrospective study with a mean follow-up of 6 years. PMID: 37917356.
Long-term dental implant survival and bone-level changes with special emphasis on radiation therapy after free fibula flap reconstruction: a retrospective study. PMID: 41207917.